Mercy Care Provider Manual

1 Mercy Care Provider ManualVisit: CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 1 of 17 Last Update: November 2018 Proprietary Mercy Care Provider Manual Table of Contents Content highlighted in yellow represents changes since the last Provider Manual iteration. CHAPTER 100 Mercy CARE Provider Manual GENERAL TERMS MC Chapter 1 Introduction to Mercy Care Welcome About Mercy Care Disclaimer MC Policies and Procedures Eligibility Hospital Presumptive Eligibility MC Chapter 2 Mercy Contact Information Mercy Care Contact Information Provider Credentialing and Contracting for all Plans Health Plan Authorization Services Table Community Resources Contact Information Table MC Chapter 3

2 Provider Relations Overview Provider Relations Overview MC Chapter 4 Provider Responsibilities - Provider Responsibilities Overview AHCCCS Registration Appointment Availability Standards Telephone Accessibility Standards Covering Physicians Locum Tenens Verifying Member Eligibility Preventive or Routine Services Well-Woman Preventative Care Services Provider Requirements Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 2 of 17 Last Update.

3 November 2018 Proprietary Educating Members on their own Heath Care Urgent Care Services Emergency Services Primary Care Providers (PCPs) Specialist Providers Second Opinions Provider Assistance Program for Non-Compliant Members Member s Medical Records Advance Directives - Documenting Member Appointments Missed or Cancelled Appointments Documenting Referrals Respecting Member Rights Consent to Treat Minors or Disabled Members under Guardianship Health Insurance Portability and Accountability Act of 1997 (HIPAA)

4 Cultural Competency, Health Literacy and Linguistic Services Individuals with Disabilities Primary Care Provider (PCP) Assignments Plan Changes Cost Sharing and Coordination of Benefits Copayments Clinical Guidelines Office Administration Changes and Training Requirements Consent Forms Contract Additions or Terminations Continuity of Care Contract Changes or Updates Credentialing/Recredentialing Licensure and Accreditation Contract Enforcement Duty to Report Abuse.

5 Neglect or Exploitation Duty to Warn Marketing Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 3 of 17 Last Update: November 2018 Proprietary Provider Policies and Procedures Health Care Acquired Conditions and Abuse Mercy Care Web Portal Provider Directory MC Chapter 5 EPSDT EPSDT Program Overview Requirements for EPSDT Providers Health Education Periodic Screenings Nutritional Assessment and Nutritional Therapy Developmental Screening Tools PCP Application of Fluoride Varnish Pediatric Immunizations/Vaccines for Children Program Body Mass

6 Index (BMI) Blood Lead Screening Eye Examinations and Prescriptive Lenses Hearing/Speech Screening Behavioral Health Screening Dental Screening and Referrals Tuberculin Skin Testing Metabolic Medical Foods Arizona Early Intervention Program MC Chapter 6 Children s Rehabilitative Services - Children s Rehabilitative Services (CRS) Overview - Integration Initiatives - CRS Qualifying Medical Conditions - Who is Eligible for CRS MC Chapter 7 Family Planning Family Planning Overview Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 4 of 17 Last Update.

7 November 2018 Proprietary Provider Responsibilities for Family Planning Services Covered and Non-Covered Services Prior Authorization Requirements MC Chapter 8 Maternity Maternity Overview High Risk Maternity Care OB Care Management OB Incentive Program Obstetrical Care Appointment Standards General Obstetrical Care Requirements Additional Obstetrical Physician and Practitioner Requirements Provider Requirements for Medically Necessary Termination of pregnancy Reporting High Risk and Non-Compliant Behaviors Outreach.

8 Education and Community Resources Providing EPSDT Services to pregnancy Members under Age 21 loss of AHCCCS Coverage during pregnancy Pre-Selection of Newborn s PCP Newborn Notification Process MC Chapter 9 Non-Emergency Transportation Non-Emergency Transportation Covered Services Program Specific Requirements Documentation Requirements Data and Reporting Professional Standards and Responsibilities Vehicle Requirements Performance Improvement Performance Outcome Measures Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 5 of 17 Last Update.

9 November 2018 Proprietary MC Chapter 10 Behavioral Health Assessments and Treatment/Service Planning Behavioral Health Assessments and Service Planning Overview Assessments Minimum Elements of the Behavioral Health Assessment Provider Submits a Complex Case Request Update to Assessment and Service Plan Transfer Assessments MC Chapter 11 Care Management and Disease Management Care Management and Disease Management Overview Referrals Care Management HIV/AIDS High Risk OB Behavioral Health Disease Management Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF)

10 Diabetes Active Health MC Chapter 12 Concurrent Review Concurrent Review Overview MILLIMAN Care Guidelines Discharge Planning Coordination Physician Medical Review MC Chapter 13 Pharmacy Management Pharmacy Management Overview Updating the Preferred Drug Lists (PDLs) Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 6 of 17 Last Update: November 2018 Proprietary Notification of PDL Updates Prior Authorization Required Over the Counter (OTC) Medications Generic vs.